Safety Leadership

Safety Leadership: From incident investigations to event learning: A paradigm shift


Editor’s Note: Achieving and sustaining an injury-free workplace demands strong leadership. In this monthly column, experts from global consulting firm DEKRA share their point of view on what leaders need to know to guide their organizations to safety excellence.

Although most safety programs include a process for investigating incidents, investigations frequently fall short of yielding actionable insights or helping reduce risks. As a result, the true return on incident-investigation investments is minimal.

Leading organizations are rethinking incident investigations to better address information gathering, data analysis, development of corrective actions and leveraging incident intelligence for systemic learning.

What incidents should I investigate?

Identifying incidents with serious injury and fatality potential is an important shift in the safety field. Organizations can drive investigations based on an incident’s potential. This approach works for any incident, whether it involves process safety or personal safety.

Legacy practices often require the investigation of every recordable incident or other outcome-based measures. Leading organizations are using an evaluation of incident-outcome potential as the trigger for investing in investigations. Not only should SIFs receive a full and thorough investigation, but also events with the potential for a serious outcome.

Take advantage of well-designed risk registers as well as hazard and operability studies, which detail exposures and controls. They can serve as the foundation for conducting incident investigations, as they help identify whether the exposure was overlooked or the controls didn’t function as expected.

Moving your investigation process to event learning

If you ask people what’s the purpose of an investigation, you’ll likely get answers like, “To prevent recurrence” or “To find and fix the root cause(s) of the incident.” These are both correct answers, but what does that look like in practice? A much simpler – and more powerful – answer is that the purpose of an investigation is to learn. And when we talk about learning, we should think about that from a system perspective.

Organizations that embody the attributes of event learning typically incorporate a four-step process:
Step 1: A matter of discovery. Gather all pertinent information through evidence collection, preservation, interviews, process documentation and timelines. Discovery aims to understand the exposure and its potential severity, not only the outcome of the incident. Key outputs of this step include a comprehensive incident timeline and a case narrative, all useful summaries for future analyses, executive summaries, and data collection software.
Step 2: Seek to understand. Review the risk factors involved and allow for a holistic analysis of systems, procedures, culture, equipment, training, and human and organizational performance. This step identifies incident causes, including organizational and management system deficiencies that contributed to the event.
Step 3: Corrective actions. Recommend measures to prevent recurrence. These actions must be based on the solid analysis of information from the previous steps. Consider improvements in the Hierarchy of Controls, as well as culture, leadership and HOP. Corrective actions must be validated (Did they work?), verified (Were they completed?) and sustainable (Do they last into the foreseeable future?).
Step 4: What can we learn from this? A common mistake that organizations make is to perform investigations to correct individual events, not considering the system implications (or improvement opportunities) highlighted by these individual events. These preventive actions can elevate learnings for consideration to other operations where similar risks and exposures occur. Organizations that embrace event learning find value in openly communicating the findings from all major investigations to employees and contractors.


This article represents the views of the author and should not be considered a National Safety Council endorsement.

Kevin Jeffries, CFEI, CFPS, CEAS, is the technical lead of DEKRA Process Safety ( He’s a safety professional with a 24-year track record of hands-on experience and leadership in a wide range of industrial operations. Jeffries has solid knowledge of combustible dust fire and explosion prevention risk mitigation systems, NFPA consensus standards, and OSHA and Environmental Protection Agency regulations.



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